Student Application | Maryville University

Personal Data

Parent/Legal Guardian Name*

FirstLast

Participant's Name*

FirstLast

Sex*

Female
Male

Are you a U.S. Citizen?*

Yes
No

Ethnicity*

School*

Age*

Grade or Class Level*

Home Phone*

Home Address*

Street AddressAddress Line 2CityStateZIP Code

Email*

Cell Phone*

Nearest Major Airport*

Attending Sponsoring Science Teacher*

Conditions of Attendance*

University funded
Self-funded (Cost: $145) Please make your check payable to “Maryville University.” Mail your payment to: Maryville University, Attn. Sue Arnott, College of Arts & Sciences, 650 Maryville University Dr. St. Louis, MO 63141
Observer (No charge, but food, housing and field trip transportation cannot be supplied by University)

Do you have any personal or physical problems that should be considered for food service, room assignment, or other situations?*

Yes
No

If so, please give details*

Because of special consideration of Lent will you need a fish dinner on Friday?*

Yes
No

Vegetarian meals both nights?*

Yes
No

Paper Preparation

Those students interested in becoming eligible to attend the National and International Symposium must submit a research paper .

Do you plan to submit a research paper?*

Yes
No

Science area in which it should be judged (Behavior, Biology, Chemistry, Mathematics, Physics, etc.)*

Title*

Abstract - Please type approximately 300 words describing your research study*

I plan to participate in the Poster Session to display and discuss my research?*

Yes
No

Research Assistance

Who has given you help with this research?

Name(s)

Title

Address

How long have you worked on this research (in months)?

Where was most of the research done?

Acknowledgement of Participation

Acknowledgement of Participation*

As parent or guardian, with full knowledge, I endorse this application and give consent for the above listed attendee to attend and participate in all of the Missouri Regional Junior Science, Engineering and Humanities Symposium activities at Maryville University this spring.

Permission and Binding Commitment and Agreement for the Junior Science, Engineering and Humanities Symposium

We hereby grant permission, as parents or guardian(s) of the student, to fully participate in programs and activities of the Junior Science, Engineering and Humanities Symposium (JSEHS) March 8-9, 2013 at Maryville University. We also agree to the following pertaining to the above-named student.

We give permission for release of all pertinent school data to the JSEHS Symposium for the purpose of selecting student to attend the Symposium;
We understand that transportation to and from the Symposium site and activities must be arranged by the school, student and/or family. We further understand that in case of problems of illness, disruptive behavior, or other unforeseen circumstances, we will be responsible for transportation home at any time when Symposium officials deem such dismissal necessary for the benefit of the student or others at the Symposium;
We affirm that the student does not use non-prescription addictive drugs, including alcohol and nicotine;
We will be financially responsible for any and all devious, malicious or wanton acts of vandalism, theft, or personal or property damage perpetrated by the student;
We understand that it may be necessary for Symposium officials to obtain emergency medical assistance in case of accident orsudden illness. We further understand that, in case of accident or illness, we accept responsibility for costs of medical care over and above the limited care provided by the Student Health Service. We hereby hold the Symposium and its agents and representatives harmless in the exercise of this authority;
We agree to adhere to the rules and regulations concerning students’ responsibilities while attending the Symposium. We understand that the director has the right to dismiss any student whose behavior is not consistent with the decorum, goals and standards of the Symposium;
We give permission for our student to be taken on field trips, on and off campus, and retain responsibility and liability for their welfare;
We agree that the student will participate in the completion of the questionnaires and other appropriate research projects done as part of the program’s evaluation. We also agree that photographs, electronic imagery and sound of our student taken during theprogram, papers written by him/her for the program, and similar items may be used by the Symposium in reports and public information materials. We further agree to allow the Symposium to release for educational purposes photographs and video recordings, with or without audio, of activities and projects involving the student;
We agree that so-called directory information about the student, including student’s name and address, school, year in school, and name(s) and address(es) of parent(s) may be released at the discretion of the JSEHS administrative staff;
We understand that participation in the Symposium will require a substantial time commitment and are willing to make attendance and full participation at all academic and social activities a first priority

Agreement*

We certify that the information on this application is complete and accurate and that we concur with these statements and will abide by the agreements and fulfill the commitments specified and implied by this application.